BOS Agenda Date: August 29,2006
Agenda ttem No.16

';)ounty of Santa Clara

Santa Clara Valley Health & Hospital
System

I

Public Health

HHSI3 082906
Prepared by: Amy Caita

Senior Health Care Program
Manager
Dolores Alvarado

Division Director, Health
Promotion

Submitted by: Guadalupe S. Olivas, Ph.D.
Director of Public Health

DATE:

August 29, 2006

TO:

Board of Supervisors

FROM:

Kim Roberts

Acting Executive Director, Santa Clara Valley Health & Hospital System

SUBJECT: HIV/AIDS Testing Expansion Implementation Plan

RECOMMENDED ACTION

Accept report relating to the Public Health Department’s HIV/AIDS Testing Expansion
Implementation Plan.

Board of Supervisors; Donald F. Gage. Blanca Alvarado, Pete McHugh, Jim Beall. Liz Kniss
1

BOS Agenda Date: August 29^2006
Agenda ftem No.16

FISCAL IMPLICATIONS

No additional County General Funds are required as result of this action. The Board of
Supervisors approved $375,000 in one-time funds as part of the FY07 budget process.

Inventory Item 1 l(i) on May 24 recommended $75,000 for necessary Public Health
Department administrative and campaign costs, and approximately $75,000 for each full time
testing service location.
REASONS FOR RECOMMENDATION

Increasing rates of HIV infection are posing threat to the public health of Santa Clara County.
Both the Center for Disease Control(CDC)and local estimates indicate that about 25% of

those living with HIV/AIDS are unaware of their diagnosis. In Santa Clara County, there are
an estimated 898 persons who are living with HIV/AIDS who are unaware of their diagnosis.
Identifying these individuals through community-based testing and counseling services will
increase their ability to seek early treatment and supportive care. Additionally, increasing the
numbers of persons tested for HIV infection will increase the Public Health Department’s
ability to support data-driven funding from state and federal sources.
This implementation work plan for alternative rapid HIV test sites reflects the voice of the
community. Public Health has participated in several meetings with representatives of the
HIV Planning Council and the HIV Prevention Community Planning Group. Their priorities
and concerns are incorporated throughout this implementation plan, which both groups have
unanimously approved. The implementation work plan is also consistent with the Santa Clara
County Comprehensive Plan for HIV/AIDS Services 2006-2008 and the Santa Clara County
HIV Prevention Plan 2006-2008.

BACKGROUND

On June 6, 2006 the Board of Supervisors approved a one-time budget allocation of $375,000
for FY 2006-07 for expansion of HIV testing and counseling sites for targeted at-risk
populations in Santa Clara County. Seventy-five thousand ($75,000) of this funding was
recommended by the Health and Hospital Committee for the Public Health Department to use
for administrative and campaign marketing costs. The purpose of this allocation is to address
gaps and barriers to the continuum of HIV services in the county by (1) Expanding testing and
counseling sites to targeted communites;(2) Expanding availability of Rapid testing sites;(3)

Board of Supervisors: Donald F. Gage. Blanca Alvarado, Pete McHugh,Jim Beall, Liz Kniss
2

BOS AgefMla Date: August 29,2006
Agenda ftem No,16

^,xpanding Outreach and Counseling by increasing the number of certified counselors; and (4)
Continuing to work with medical providers regarding reporting requirements via the
Department's Surveillance Unit.

The Public Health Department was requested to submit an implementation plan for review by
the Health and Hospital Committee. The Health and Hospital Committee accepted this plan at
its August 16, 2006 meeting.
Purpose. Goals, and Parameters of Plan

The goal of the HIV/AIDS Testing Expansion program is to reduce the prevalence and
incidence of HIV/AIDS through testing, counseling, referral to care and treatment to residents
who are at risk of HIV/AIDS by;
• Increasing the number of certified test counselors in the community.
• Conducting a minimum of 6,944 tests in the target population, 2% of which will test
positive for HIV antibodies(140 positive results).
Priority Populations for Expanded HIV Alternative Testing Sites are:
• Men who have sex with Men(MSM)

• Eemale sexual partners of Men who have Sex with Men(ESMSM)
• Transgender persons and Injection Drug Users(IDU)
•(IDU) and MSM/IDU

Groups identified among priority populations for expanded HIV testing are:
• People of Color
• Sex Workers
• Youth

Geographic Area Priorities are;
• The HIV/AIDS epidemic continues to be concentrated in the city of San Jose.
• North County residents (Sunnyvale, Mountain View, Palo Alto and Los Altos)
make-up the next highest percentage of reported HIV cases.

• South County residents make-up the smallest number of reported HIV cases to date.
• However, isolation and limited access to services create challenges that need special
attention.

Board of Bupervisors: Donald F. Gage, Blanca Alvarado, Pete McHugh,Jim Beall, LizKniss
3

BOS Agenda Date: August 23,-2006
Agenda ttetin No.16

Method to Expand HIV Testing

The Public Health Department will use a competitive RFP process to select 3 to 5 community
based organizations to provide HIV testing and counseling within the required standards
stipulated by the California Department of Health Services(CA DHS)and the CDC. These
required standards have been incorporated as necessary "start-up" infrastructure development
that selected Community Based Organizations(CBO) will need to have in place prior to
beginning the testing. Accordingly, the contract period will be November 1, 2006 to October
31,2007.

Attachment 1 outlines the timetable for implementing this plan. The specific work plan
activities are detailed in Attachment 2.

Included in pages 1 and 2 of this work plan (Attachment 2) are the preferred capacities and
requirements for community based organizations.

The detailed activities and timeframe necessary to meet the CA DHS and CDC requirements
are delineated on page 3.

To maximize awareness of the availability of the expanded testing sites, the Public Health
Department(PHD) will develop a marketing campaign. To complement this new General
Fund funding, the PHD has also been able to restructure the availability of its internal testing
services by assigning its County staff(2 FTE)during nontraditional hours. The Department is
in the process of accomplishing this through the meet and confer process with SEIU 715. In
addition, to manage and monitor this expanded program, the PHD will redirect HAP staff to
undertake functions listed in Attachment 2.

Einally, the implementation of this program will include an evaluation of the degree to which
the outlined goals and objectives have been achieved. The detailed evaluation plan is included
in Attachment 3.

Board of isupervisors: Donald F. Gage, Blanca Alvarado, Pete McHugh, Jitn Beall, LizKniss
4

BOS Agenda Date: August 29,2006
Agenda Item No.16

CONSEQUENCES OF NEGATIVE ACTION

i^ailure to accept this report will delay implementation of the plan to expand HIV/AIDS
testing sites in the community.
ATTACHMENTS

• Attachment 1 - RFP Timeline

• Attachment 2- Workplan Table
• Attachment 3 - Evaluation

Board of Bupervisors: Donald F. Gage, Blanca .Alvarado, Pete McHugh, Jim Beall, Liz Kniss
5

This page is intentionally left blank.

ATTACHMENT 1

HIV Rapid Testing and Counseling Expansion Program
Implementation Plan and Proposed RFP Process

June 28

PHD management staff meets with Prevention Community
Planning Group(CPG)Chairs to discuss components of
Implementation Plan.

June 30

PHD begins drafting Implementation Plan

July 13

Dr. Olivas met with Planning Council Executive Committee - to
present draft Plan and solicit input.

July 19

Dolores Alvarado and Kevin Hutchcroft to meet with HIV/AIDS

Providers and CPG to present final draft Plan (inclusive of
recommendations by CPG)and solicit further input.
July 20-25

August 16

Incorporate CPG recommendations into implementation plan.

Health & Hospital Committee accepts plan and forwards a positive
recommendation to the BOS.

August 29

Board of Supervisors approves Plan.

August 30

Request for Proposals(RFP)is released via posting on county
website RFP Depot.

September 8

RFP Information Meeting (Voluntary)
770 S. Bascom, room #136,3:00-5:00 PM

September 20

Applications due to Public Health Administration by 5:00 p.m.

September 27

Review Committee meets to review proposals

October 2

Accepted Proposals are announced.

October 3-31

Contract service agreements are developed, finalized and approved
by county.

November 1

12-month Program implementation begins.
CBO’s begin developing their infrastructure (hiring staff;
developing policies & procedures; training staff, etc.)

January 1, 2007-

Expanded testing services begin and continue at all sites.

October 2007
November 2007

Evaluation of Program.

This page is intentionally left blank.

Attachment 2

Building Capacity for Increased HIV Alternative Testing Sites in Santa Clara County:
HIV/AIDS Testing and Counseling Expansion
Implementation Workplan

Community Agfency Role: Preferred CapladtHs^^n^lE^^^
All Community-based Alternative Testing Sites will use Rapid Testing technology to provide
voluntary, anonymous and confidential free HIV testing. The goal is to make rapid testing
accessible to the most at-risk populations in the county(MSMs—Men who have sex with men,
MSM Methamphetamine users, FSMSMs—Females who have sex with MSM,IDUs—Injection

drug users, MSM IDUs, and Transgender sex workers & IDUs). Additionally, it is important that
the following populations are addressed within each target group: people ofcolor, sex workers,
and youth. Part of making testing accessible also means to provide testing in the San Jose area,
where the HIV/AIDS epidemic is concentrated, as well as in North County, which has the next
highest percentage of reported HIV cases, and in South County, where isolation and access to
services is a challenge

Requirementsfor Alternative Testing Sites:
All testing sites must operate in compliance with relevant state and local regulations and CDC
guidelines applicable to HIV Rapid Testing. (HAP will provide technical assistance to CBOs in
preparing Alternative Testing Sites.)
Santa Clara County receives an annual allocation of HIV Education and Prevention funds to

reduce new HIV infections, the purpose of which is to prevent and interrupt the the transmission
of HIV through preventive individual, group or community-level interventions to target
populations other than test counseling. The Department of Health Services, Office of AIDS
directs Local Health Jurisdictions to coordinate closely their HIV test-counseling programs with
HIV prevention providers in receipt of State Education and Prevention funding. All HIV
Education and Prevention subcontractors receive HIV testing certification training and test kits
without charge from the State Office of AIDS.

Thus, given the complexity of setting up and operating an HIV testing site, history as a recipient
of HIV Education and Prevention Funding or collaboration with a previous recipient of HIV
Education and Prevention Funding will be required for funding. This histoiy and background
will facilitate an easier start-up of services and will enhance the CBO’s ability to access testing
kits and consultation services from the State Office of AIDS.

Preferred Capacities:

■
■
■

Culturally competent and appropriate outreach, testing and counseling for the county’s
populations most at-risk and in communities prioritized in this implementation plan.
Demonstrated access to and established trust with targeted high-risk populations.
Effective collaboration with care and support services for HIV/AIDS clients.

■

Capacity for effective health education dissemination.

■

Strategies as cost-effective as possible, such as, making use of community volunteers as test
technicians and counselors when they can effectively reach the target population.

1

Attachment 2

Activities

Meet HIV testing certification requirements:
■ Participate in mandatory certification training(60
hours).
■ Participate in annual continuing education training
to keep certificate up-to-date.
■ Perform at least 12 tests per month.

Participate in trainings and meetings as arranged by
HAP.

Responsible Party

Timeframe

CBO/ATS Staff and

11/2006-1/2007

Volunteers

CBO/ATS Staff and

Ongoing

Volunteers
CBO Administration

11/2006

CBO/ATS Staff

11/2006-1/2007

Develop systems and procedures to ensure client
privacy and confidentiality.

CBO/ATS Staff

11/2006-1/2007

Establish procedures for protecting all client-related

CBO/ATS Staff

11/2006-1/2007

CBO/ATS Staff

11/2006-1/2007

Identify coordinator for ATS project.
Select Alternative Testing Sites:
■ Identify sites at high-risk venues: bathhouses, gay
bars, adult bookstores, head shops, parks or public
sex environments, areas frequented by injection
drug users, and areas frequented by sex workers—
transgender MTF
(male to female)and heterosexual females—near
gas stations, convenience stores, in parks in East
San Jose, Needle Exchange Program Sites,
homeless shelters, and chemical dependency
programs.

■

Assess proposed settings for feasibility of
implementing rapid HIV testing (e.g., acceptable
lighting for test readability, temperature control,
and private space for providing test results).

■

Coordinate with the ATS Coordinator to ensure

priority risk behavior and geographic coverage
(San Jose area plus North and South County).
Create a site plan (locations and schedules).

data.

Develop systems and procedures for informed consent
procedures in accordance with local and state
requirements and CDC guidelines.
■ Establish unambiguous and easy to implement
guidelines to define sobriety standards and to
identify chronic mental health conditions that may

2

Attachment 2

interfere with ability to provide informed consent.
Develop a process to document consent for testing
and testing results, and to track specimens sent for
confirmatory testing.

CBO/ATS Staff

11/2006-1/2007

Develop a process for obtaining detailed locating

CBO/ATS Staff

11/2006-1/2007

Develop a plan to ensure compliance with the Clinical
Laboratory Improvement Amendment(CLIA)and
with relevant state and local regulations applicable to
HIV Rapid Testing.

CBO/ATS Staff

11/2006-1/2007

Develop a plan for handling infectious waste,
complying with the regulations of the Occupational
Safety and Health Administration, and handling
potential exposures.

CBO/ATS Staff

11/2006-1/2007

Develop a plan to maintain staff and volunteer safety
at settings that may pose a risk to them (e.g., safety
training and taking precautions, such as, working in

CBO/ATS Staff

11/2006-1/2007

CBO Staff

On-going

CBO Staff

2/2007-11/2007

CBO Staff

2/2007-11/2007

2/2007-11/2007

information on clients whose test results are

preliminary positive so that they can be contacted and
encouraged to come in for care if they fail to return
for their follow-up appointment.

teams).

Participate in site visit by ATS Coordinator.
Operate alternative test sites and outreach at high-risk
venues, as coordinated with Test Site Coordinator.

■

Provide HIV testing and counseling to high-risk
clients(MSMs, MSM Methamphetamine users,
FSMSMs, IDUs, MSM IDUs, and Transgender
sex workers & IDUs).

■

Provide condoms for prevention (harm reduction).

Collect Data:

■

Complete the HIV Counseling Information Form
(CIF), Lab Slips and Testing Consent Forms for
all clients; HIPAA consent for confidential

clients; and any additional recordkeeping required
by HAP.
Manage Referrals:

■

Arrange linkages with medical and social referrals
for comprehensive follow-up.

CBO Staff

•

Develop procedures for making referrals, assisting
clients with getting to referrals, and confirming

CBO Staff

that referred clients acted on the referrals and

3

Attachment 2

received, or are receiving, services as a result of
the referral.
CBO Staff

Participate in Public Health Department evaluation.

1 1/2007-

12/2007

Public Hpalth RoIer tiOversiglit and Technical Assistance
The Public Health Department plays an important role in the implementation of the HIV
alternative test sites. Its roles and responsibilities operate within the context of the California
Department of Health Services/Office of AIDS(DHS/OA)requirements. DHS/OA requires that
each local health jurisdiction (public health department) provide free anonymous and
confidential HIV test counseling services at one fixed-site location for persons seeking an HIV
test, the Alternative Testing Site (ATS). The Public Health Department’s Crane Center serves as
Santa Clara County’s ATS. The DHS/OA allows each local health jurisdiction to assign this
status to other community sites, and, thus, create additional Alternative Testing Sites. These
additional ATSs are typically located in specific geographic, ethnic or cultural communities.
This FY 06 General Funding will create 3 to 5 ATSs managed by CBOs. The DHS/OA requires
the Public Health Department to authorize and monitor ATSs.

Public Health Departmient Adiiiinistration
Activities

Responsible Party

Timeframe

HIV/AIDS Program
Manager w/

8/30/06-1/15/07

Develop and Implement a Social Marketing Campaign;
■

Develop campaign:
o

Develop a common message that will be
used with all target audiences(MSMs,

consultation from

MSM Methamphetamine users,

Public Health

FSMSMs,IDUs & MSM IDUs,

Information Officer

Transgender sex workers & IDUs).

(PIO)and a Marketing
Consultant.

o

o

8/30/06 -

Communicate program goals and
strategies to a variety of constituencies.

1/15/07

1/15/07-

Distribute marketing materials to CBOs.

11/2007

1/2007-11/2007

■

Implement campaign.

Analyze Data;

■
■

to Improve HIV Surveillance.
to provide feedback to HAP to assist them in
Alternative Testing Site(ATS)coordination.

Data Management and

Ongoing

Statistics

4

•v

Attachment 2

Public Health Department Administration (continued)
Activities

Evaluate the Project:
■

Design evaluation.

■

Implement evaluation.

■

Report results.

Responsible Party
Division Director,
Community Health
Promotion, HAP, Data
Management and

Timeframe

6/2006-12/2007

Statistics

Strengthen relationships between PHD and the
Department of Alcohol and Drug Services(DADS)and
the Mental Health Department(MH)to facilitate
referrals to the county’s HIV testing and counseling.
Finalize agreement with S.E.I.U. Local 715 to be able to
assign county staff at strategic locations during nontraditional hours to provide HIV testing and counseling
to high-risk populations.

Work with County Counsel to explore the feasibility of
utilizing PHD's Testing Van by CBOs funded through is

PHD Administration

Ongoing

Health Promotion

8/15//2006

Division Director with
PHD Administration

HAP Management

Ongoing

PACE staff

7/2006-

initiative.

Provide HIV testing for clinic patients’ partners and
friends at the PACE Clinic:
■

Plan

■

Oversee implementation

Ongoing

Continue confidential and anonymous HIV testing at the

HAP

Ongoing

Crane Center.

Public Health Department HIV/AIDS Prevention and Control/program(HAP)
Activities

Responsible Party

Timeframe

PHD with HAP

9/2006-

Management

11/2006

HAP ATS

Ongoing

Administer funds:

■
•
■
■

Implement an RFP process.
Develop selection criteria.
Manage selection process.
Negotiate and finalize contracts...

Manage data collection process.

Coordinator

Monitor CBOs’ testing sites:
■

program implementation,

■

processes,

■
■

program performance,
achievement of goals and objectives, and

HAP Contract

Ongoing

Management Staff &
ATS Coordinator

5

Attachment 2

■

resource requirements.

Provide oversight and coordination to ensure the CBOs
are reaching target populations.

ATS Coordinator

Ongoing

Maintain a matrix of CBO testing sites and schedules to
provide an overview of all sites.

ATS Coordinator

Ongoing

Provide training and technical support.

ATS Coordinator

Ongoing

Coordinate training and certification for all ATS CTR

ATS Coordinator

9/2006-1/2007

Coordinate any additional training, as needed.

ATS Coordinator

Ongoing

Perform a site visit to confirm CBO readiness to begin
testing.

ATS Coordinator

12/2006-

staff and volunteers.

1/2007

Work with CBOs to identify and correct program issues.

ATS Coordinator

Ongoing

Collect information on what is working and what is not
working and share information on “lessons learned” with
all Alternative Testing Sites.

ATS Coordinator

Ongoing

Collect data.

ATS Coordinator

Ongoing

Provide routine QA to ensure that the test sites effectively
deliver a consistently high level of service to clients.

ATS Coordinator

Ongoing

Review data and assist CBOs in modifying and changing

ATS Coordinator

Ongoing

sites and schedules as new data become available to best
meet the needs of residents who are most at-risk of

acquiring HIV.

Supply Rapid Testing kits (which are supplied by
DHS/OA at no cost) to the CBOs funded to manage
ATSs:

■
■

Assemble Rapid test kits for easy storage and
transportation to each testing site.
Link with Public Health Laboratory for confirmatory
testing of preliminary positive rapid test specimens.

Enter data for the HIV Counseling Information Form
completed for all clients at testing sites by CBOs.

ATS Coordinator

1/200711/2007

8/2006 -

ongoing
HAP clerical staff

1/2007-

11/2007

6

(’

ATTACHMENT 3

HIV Rapid Testing and Counseling Implementation Plan
Program Evaluation Plan FY 08

Program Name

HIV Rapid Testing and Counseling Implementation Plan

Target Population

Residents of Santa Clara County who are High Risk Population for HIV/AIDS:(1) men who have sex with men(MSM),
(2) MSM Methamphetamine users,(3) Female partners of MSM(FSMSMs),(4)Intravenous Drug Users(IDUs)and
MSM IDUs,(5)Transgender sex workers & IDUs.

Problem Statement

Increasing rates of HIV infection in several identified populations are posing threat to the public health of Santa Clara
County. Both CDC and local estimates indicate about 25% of those living with HIV/AIDS are unaware of their diagnosis.
In Santa Clara County, there are an estimated 879 persons who are living with HIV/AIDS who are unaware of their
diagnosis. The local positive rate for testing at the Public Health Department Laboratory is 1.67%, while the statewide
average positive rate is 2.6%. The local positive rate for MSM is 2.4-4.0%, while the statewide MSM rate is 12-20%.

Overall Program

To reduce the prevalence and incidence of HIV/AIDS through testing, counseling, referral to care and treatment to

Goals

residents who are at risk of HIV/AIDS.

Program
Components

1. Assessment
2. Outreach

3. Clinical Health Services (Testing, Health Education, Counseling, Treatment)
4. Community Collaboration
Program
Description

Confidential and anonymous testing will be provided at HIV test sites. Rapid testing will be used at locations where
populations at greater risk for HIV/AIDS will be more likely to access services. Counseling and referrals are also provided
to clients as needed.

Program Theory

Health Belief Model

Trans-theoretical model (Stages of change)
Harm reduction

zc

oo

1

Program Component: Outreach, Clinical services
Measurable

Objectives

1. By December 2007,
at least 2% of

people will test
positive for HIV
antibodies among
test sites within

Program Activities to
achieve objectives
a. Targeting high-risk
populations such as
MSM,transgender,
IDUs and their

Evaluation Methodology

Data Source

Reporting

Link to ES Indicator

Timeframe

Data collection - reports from
testing sites on number of tests

HIV 6

Quarterly

ELI

Essential Service(ES)7:

Link people to needed

conducted, results and

health services and assure

demographics of clients

the provision of health care
when otherwise

partners, and females
having sex with MSM.

unavailable.

Santa Clara County.
b. Conducting at least
6944 HIV tests

Program Component: Clinical services (counseling and referral)
Measurable Objective

2. By December 2007,

Program Activities
to achieve objectives
a. Training staff on

100% of clients who

resources available

sessions and number of

are HIV positive will

to refer clients

staff participating

Evaluation Methodology

Providing
adequate resources
to clients

Reporting

Link to ES Indicator

Timeframe

a. Count number of training

be referred to care.
b.

Data Source

b. Determine percentage of
clients referred to care

Report from testing site on # of
referrals to which providers

a. Staff reports
& survey
staff who

Quarterly

Essential Service(ES)7:
Link people to needed
health services and assure

received

the provision of health

training

care when otherwise
unavailable.

b. HIV 6

Record of follow-up activities
(phone calls to clients,
providers, etc.)
Record of referral information

provided to client

\

2

I

Program Component: Community collaboration
Measurable objective
3. By December 2007, at
least 70% of the

community providers
and partners will
report high level of

Program activities
to achieve objectives

a. Conducting focus
groups

b. Administering the
Community

satisfaction with the

Provider and

public health
department

Partner

Evaluation methodology

Data source

Reporting

Link to ES indicator

Timeframe

a. Conduct 2 to 3 focus groups
with community providers
and partners

a. Notes/

Annual

Results from

Essential Service (ES)7:
Link people to needed

focus groups

health services and assure

the provision of health care
b. Analysis of results from
satisfaction survey to
community providers

Satisfaction

b. Provider and

when otherwise unavailable.

Partner

satisfaction
surveys

Surveys
Program Component: Clinical Health Services
Measurable objective
4. By the end of

Program activities
to achieve objectives
a. Conducting client

December 2007, at

satisfaction

least 80% of the

surveys focusing
on the quality and
accessibility of the
services provided

clients will report high
levels of satisfaction

with the Community

Evaluation methodology

Data source

Reporting

Link to ES indicator

Timeframe

Analysis of survey results
(SPSS)

Client

Quarterly

satisfaction

Essential Service (ES) 7:
Link people to needed

survey

health services and assure

the provision of health care
when otherwise unavailable.

Based Organizations
providing services.

3

Program Component; Community collaboration, clinical services
Measurable objective

Program activities
to achieve

Evaluation

Data source

Reporting

Links to ES indicators

Timeframe

methodology

objectives

5. By the end of December

a. Include

Analysis of survey

Client satisfaction

results (SPSS)

survey

Quarterly

Essential Service (ES) 7:
Link people to needed health

2007, 100% of clients

question(s) on

who participate in the

the client

risk reduction

satisfaction

provision of health care when

counseling session will

survey to

otherwi.se unavailable.

have increased

assess whether

knowledge of personal
HIV/AIDS prevention
strategies.

increase in

services and assure the

there was

knowledge
about HIV

prevention

* The Centers for Disease Control’s(CDC)National Public Health Performance Standards Program’s Ten Essential Services of Public Health
document presented a method to organize the many diverse programs within the Department and support conclusions about overall department
impact. The essential services represent the ten core responsibilities of a local department of public health.

\

4